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MANAGEMENT OF Suspected and Confirmed SMALL

FOR GESTATIONAL AGE (SGA) from 20 weeks gestation
This guidance does not override the individual responsibility of health professionals to make
appropriate decision according to the circumstances of the individual patient in consultation with
the patient and /or carer. Health care professionals must be prepared to justify any deviation
from this guidance.

INTRODUCTION
SGA is a significant contributor to perinatal morbidity and mortality. The aim of antenatal
diagnosis and appropriate management of SGA is to reduce perinatal mortality and morbidity,
primarily by optimising the timing of delivery of the affected fetus.
Fetuses identified as small for gestational age (SGA) during the antenatal period, comprise a
heterogeneous group in regard to aetiology, management and prognosis.
Incorrect dating of the pregnancy is a common problem in late bookers / un-booked pregnancy
and may be mistaken for small for gestation age.
In accurately dated pregnancies the fetuses identified as SGA are:
 80-85% Constitutionally small but healthy
 5-10% Chromosomal/ structural anomalies/ intrauterine infection
 10-15% True SGA

One of the most important aims of effective antenatal care is the detection of the fetus at risk
from SGA.
This guideline incorporates the RCOG Green-top guideline number 31. It is an
interim guideline based on the resources available within the Trust. Limited
adoption of the Green-top guideline has been confirmed by other Trusts within the
region and nationally.

THIS GUIDELINE IS FOR USE BY THE FOLLOWING STAFF GROUPS:

Medical staff and midwives

Lead Clinician(s)

Miss R Duckett Consultant Obstetrician and

Gynaecologist
Mr S Agwu Consultant Obstetrician and
Gynaecologist
Aldonna Morrison Midwife Sonographer

Margaret Stewart Matron for Antenatal services

Approved by Accountable Director on: 16th September 2015

This guideline should not be used after end of: 16th September 2017

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Key amendments to this guideline

Date Amendment By:
19.05.10 Changes to management flowchart p5. Mr S Agwu/Miss R Imtiaz
22.05.12 Changes to management of SGA >36 weeks of gestation Mr S Agwu/Dr M Vij/
Miss R. Imtiaz
April 2013 RCOG guideline hyperlinked onto front page Rachel Duckett
July 2013 Removal of link to the RCOG on the front sheet Rachel Duckett
July 2013 Reviewed Changes in line with RCOG Guidance Dr Claire Bailey
Nov 2013 Review and made changes in line with RCOG Guidance Mr S Agwu,Rachel
Sept 2014 Duckett, A. Morrison, M.
Stewart
June 2015 Additional explanation re correlation between SFH Rachel Carter – Matron for
measurement and EFW measurement Inpatient services

Guidelines to be used in conjunction with this guideline include:

Antenatal steroids (WAHT-OBS-008 PPROM guidelines)

In-utero transfer (WAHT-OBS-055 In-utero transfer)
Preterm Labour WAHT-OBS-007 Spontaneous preterm labour

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MANAGEMENT OF SMALL FOR GESTATIONAL AGE (SGA)

INTRODUCTION
SGA is a significant contributor to perinatal morbidity and mortality. The aim of antenatal
diagnosis and appropriate management of SGA is to reduce perinatal mortality and morbidity,
primarily by optimising the timing of delivery of the affected fetus.
Fetuses identified as small for gestational age (SGA) during the antenatal period, comprise a
heterogeneous group in regard to aetiology, management and prognosis.
Incorrect dating of the pregnancy is a common problem in late bookers / un-booked pregnancy
and may be mistaken as small for gestation age.
In accurately dated pregnancies the fetuses identified as SGA are:
 80-85% Constitutionally small but healthy
 5-10% Chromosomal/ structural anomalies/ intrauterine infection
 10-15% True SGA
One of the most important aims of effective antenatal care is the detection of the fetus at risk
from SGA.

GUIDELINE
Risk factors to be identified at booking

(In women at high risk of developing pre – eclampsia, Aspirin should be commenced by 16
weeks gestation.)

All women should be assessed at booking for risk factors for the development of a SGA fetus to
identify those who will require increased surveillance.
Factors that increase the likelihood of small for gestational age can be classified as either minor
or major;

Minor Risk Factors

- Maternal age ≥ 35 years at booking
- Nulliparity
- BMI < or = to 19
- BMI >35
- Smoker 1-10 / day
- Previous pre-eclampsia

Major Risk Factors

- Maternal age > 40 years at booking
- Smoker > 11 / day
- Cocaine abuse
- Previous stillbirth
- Previous SGA
- Chronic hypertension
- Diabetes
- Vascular disease
- Renal impairment
- Antiphospholipid syndrome
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- Heavy bleeding after 12 weeks gestation

- Echogenic bowel
- Previous eclampsia
- Severe pregnancy induced hypertension
- Unexplained APH
- PAPP-A < 0.4MoM
- Abnormal uterine artery Doppler at 20 – 24 weeks

RISK FACTORS ARE NOT ABSOLUTE AND CLINICAL DISCRETION SHOULD BE

EMPLOYED

Women with three or more minor risk factors should be referred for Consultant led care and
scan follow up arranged as per the risk factors. As a minimum a third trimester scan should be
arranged.

Women with one or more major risk factor(s) should be referred for Consultant led care and
have serial ultrasound measurement of fetal size and assessment with umbilical artery Doppler
from 26-28 weeks.

Investigation of SGA

If severe SGA is identified at the 20 week scan then the woman should be referred to a fetal
medicine specialist for a detailed anatomical survey and uterine artery Doppler. These women
should be discussed with the Consultant Obstetrician on call.

Karyotyping should be offered in severely SGA foetuses with structural anomalies and in those
detected prior to 23/40, especially if the uterine artery Doppler is normal.

Serological screening for Cytomegalovirus and Toxoplasmosis should be offered in severely

SGA foetuses.
Testing for syphilis and malaria should be considered in high risk populations.
Estimated Fetal growth should be assessed at each antenatal visit from 24 weeks, by
measuring the symphysis fundal height (SFH) and this should be plotted on the customised
growth chart. SFH should be measured and plotted at every visit with intervals = or greater than
2 weeks.
Referral for suspected SGA

Symphysis fundal height(SFH) should be measured and plotted on a customised chart at each
antenatal appointment from 24 weeks of pregnancy as this improves prediction of a SGA
neonate.

Indications to refer for ultrasound assessment include:

 A single SFH measurement that plots less than the 10th centile.
 If during the course of the antenatal care the SFH measurements cross the centiles.

Whilst estimated fetal weight (EFW) and Symphysis fundal height (SFH) may each be plotted
on the customised GROW chart, there is no correlation between SFH and EFW measurements.
On this monitoring tool EFW is an indication of fetal weight and SFH an indication of uterine

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growth. Comparision should only be made between measurements of the same kind to
determine consistent or concerning growth (i.e. SFH and subsequent SFH).

If fetal growth restriction is suspected on clinical grounds follow the pathway below.

Management of suspected SGA

Low risk women booked under midwifery led care

 If there is a suspicion of static fetal growth on SFH measurement when plotted on the
customised chart or a crossing of centiles on SFH measurement with no other
concerning features (such as reduced fetal movements or other medical complications)
the midwife should call the scan department to book a growth scan as a priority (within a
week). If there is a problem in arranging an urgent scan the midwife should speak
directly to the sonographer explaining the need for the scan.
 If the woman also has reduced fetal movements or other medical complications she
should be referred to the registrar/consultant on-call for a more urgent plan of care.
 If the SFH plots below the 10th centile regardless of the pattern of fetal movements the
woman should be reviewed by the obstetric team on the same day.
 The midwife should review the scan and if growth is satisfactory no further scans are
required and should only be repeated if further discrepancy is identified on SFH
measurements.
 If on the basis of the growth scan there is a drop in the growth when plotted on the
customised chart or CMW cannot arrange a growth scan, the women should be referred to
the on-call medical staff (on-call registrar/consultant) and be reviewed the same day in
obstetric day assessment unit/ delivery suite.
 After medical review if it is felt that a growth scan is urgently needed it should be booked
with the scan department. The on-call registrar/ consultant may have to personally speak to
the sonographers to request the scan in such a situation.
 A further plan should be made (on the basis of estimated growth / amniotic fluid volume /
umbilical arterial Dopplers / CTG / fetal movements) by the on-call registrar in liaison with
the consultant on call prior to the patient leaving hospital.
 If follow up scans or medical review is required this should be arranged within the antenatal
clinic setting as the obstetric day assessment unit is not meant for regular antenatal check
ups for high risk patients. Care should ideally remain with the daytime consultant on call on
the day of referral if possible.

Women booked under consultant led care

If growth restriction is suspected in women booked under consultant care:
o A growth scan should be arranged as a priority (within a week). The clinic midwife/ registrar
or consultant may have to personally speak to the sonographers.
o If follow up appointments are not available in the clinic to review the woman with scan soon
enough she should be seen and the scan reviewed in the obstetric day assessment unit by
the on call registrar/ consultant.
o For such a patient a further follow up appointment should be made for the consultant clinic
if possible as obstetric assessment unit is not meant for regular antenatal check up for high
risk patients and the care should remain with own consultant.

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Management of confirmed SGA

If USS confirms fetal growth restriction then follow the flow chart on management of IUGR.
(APPENDIX)

INTERVENTIONS:
o Women with a SGA fetus between 24+0 and 35+6 weeks of gestation, where delivery is
being considered, should receive a single course of steroids.
(If delivery by Caesarean section is being considered prior to 38+6 weeks gestation then
steroids should be given).

SURVEILLANCE:
o In a high risk population, the use of umbilical artery Doppler has been shown to reduce
perinatal morbidity and mortality and should be the primary surveillance tool in the SGA
fetus.
o When umbilical artery Doppler flow indices are normal surveillance can be repeated
every 14 days. In severe SGA however it may be more appropriate to repeat
surveillance more frequently.
o When umbilical artery Doppler flow indices are abnormal (pulsatility or resistance index
>+2 SDs above the mean for the gestational age) and delivery is not indicated then
repeat surveillance twice weekly if EDF is present and daily if absent or reversed
EDF.(AREDF)
o CTG should not be the only form of surveillance in SGA foetuses. However, if Doppler is
not available on a daily basis (such as at weekends or holidays), then CTG should be
performed at least daily (Frequency based on the clinical picture.)
o Interpretation of the CTG should be based on the short term fetal heart rate variation
from computerised analysis.
o Ultrasound assessment of amniotic fluid volume should not be used as the only form of
surveillance in SGA foetuses.
o Interpretation of amniotic fluid volume should be based on single deepest pool.
o Middle cerebral artery (MCA) Doppler may be useful in timing delivery but should only
be used after 32 weeks gestation.
o Ductus venosus (DV) Doppler should be used for surveillance in the preterm SGA fetus
with abnormal umbilical Dopplers to time delivery.

TIMING OF DELIVERY
There is general consensus that delivery is indicated when the risk of fetal death or significant
morbidity from continuing with the pregnancy is greater than the risk of prematurity.

 Infant mortality at or after 32 weeks is low and immediate delivery can be supported for at
risk fetuses.
 Infant mortality before 32 weeks rises steadily due to immaturity of the fetus and delaying
delivery may be beneficial provided umbilical artery Doppler demonstrate EDF, amniotic
fluid volume is normal and there are good fetal movements.

Before 32 weeks

o If umbilical artery AREDV is detected prior to 32 weeks then delivery is recommended

when ductus venosus (DV) Doppler is abnormal or UV pulsations appear. Even if
venous Doppler is normal, delivery is recommended by 32 weeks and should be
considered between 30 – 32 weeks gestation.
o In the preterm SGA fetus, middle cerebral artery (MCA) Doppler should not be used to
time delivery.
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After 32 weeks

o When SGA is detected after 32 weeks with abnormal umbilical artery Doppler then
delivery should not be later than 37 weeks.
o If the umbilical artery Doppler is normal then timing of delivery should involve a senior
obstetrician but delivery should be offered at 37 weeks.
o In the term SGA fetus with normal umbilical artery Doppler, an abnormal MCA Doppler
has a moderate predictive value for acidosis at birth and should be used to time delivery.

MODE OF DELIVERY
o In the SGA fetus with AREDV delivery by caesarean section is recommended.
o If umbilical artery Doppler is normal or if abnormal but with end-diastolic velocities
present then IOL can be offered.
o Continuous fetal heart rate monitoring is recommended from the onset of uterine
contractions. These women should be given ranitidine as the rates of emergency C/S
are increased.
o Early admission is recommended in women with spontaneous labour with a SGA fetus
to order to commence continuous fetal monitoring.

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MONITORING TOOL
How will monitoring be carried out? Clinical audit
Who will monitor compliance with the guideline? Obstetric Clinical Governance and Risk
Committee

STANDARDS % CLINICAL EXCEPTIONS

Referral to consultant unit if growth <10th centile 100% None
Referral to consultant unit if fundal height crossed a
centile
REFERENCES

1. Weiner CP et al. Fetal Growth restriction: evaluation and management. High risk
pregnancy: management option. London: WB Saunders, 1999.

2. Coomarasamy A et al. Royal College of Obstetrician and Gynaecologists. Guideline no 31.

The Investigation and management for small for gestational age fetus.

3. Owen P et al. Prediction of intrauterine growth restriction with customised estimated fetal
weight centiles. BJOG 2003;110:411-5

4. GRIT study group. A randomized trial of timed delivery for the compromised preterm fetus:
short term outcomes and Bayesian interpretation. BJOG 2003;110:27-32.

5. DIGITAT study group. Neonatal morbidity after induction vs expectant monitoring in

intrauterine growth restriction at term: a sub analysis of DIGITAT RCT. Am J Obstet
Gynecol. 2012 Jan 13.

6. RCOG. The Investigation and Management of the Small for Gestational Age Fetus: Green
Top Guideline number 31, 2014

ABBREVIATIONS USED IN GUIDELINE:

AC Abdominal Circumference
AEDF Absent End Diastolic flow
AFI Amniotic Fluid Index
AFV Amniotic fluid volume
BMI Body Mass Index
CMV Cytomegalo virus
CTG Cardiotocograph
EDF End diastolic flow
EFW Estimated fetal weight
FM Fetal movement
IOL Induction of labour
IUGR Intrauterine growth restriction
MPD Mean pool depth
NICU Neonatal Intensive Care Unit
REDF Reverse End diastolic flow
RI Resistance Index
SFH Symphysis fundal height
SGA Small for gestational age
UA Umbilical Artery
UAD Umbilical Artery Doppler

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CONTRIBUTION LIST

Key individuals involved in developing the document

Name Designation
Miss R Imtiaz Consultant Obstetrician
Mr S Agwu Consultant Obstetrician/Gynaecologist
Miss R Duckett Consultant Obstetrician/Gynaecologist

Circulated to the following individuals for comments

Name Designation
Mrs P Arya Consultant Obstetrician/Gynaecologist
Mrs A Blackwell Consultant Obstetrician/Gynaecologist
Miss R Duckett Consultant Obstetrician/Gynaecologist
Mrs S Ghosh Consultant Obstetrician/Gynaecologist
Mr J Hughes Consultant Obstetrician/Gynaecologist
Miss M Pathak Consultant Obstetrician/Gynaecologist
Mrs J Shahid Consultant Obstetrician/Gynaecologist
Ms D Sinha Consultant Obstetrician/Gynaecologist
Ms L Thirumalaikumar Consultant Obstetrician/Gynaecologist
Mr A Thomson Consultant Obstetrician/Gynaecologist
Mr J Uhiara Consultant Obstetrician/Gynaecologist
Mr J F Watts Clinical Director/Consultant Obstetrician/Gynaecologist
R Fletcher Clinical Pharmacist
P Paine Head of Midwifery
K Kokoska Maternity Services Risk Manager
R Carter Matron
A Talbot Matron
M Stewart Matron
R Carter Matron/Supervisor of Midwives
M Stewart Matron/Supervisor of Midwives
A Talbot Matron/Supervisor of Midwives
A Bennett/F Pagan Delivery Suite Managers, Alexandra Hospital
P Jones Delivery Suite Manager, WRH

Circulated to the chair of the following committee’s / groups for comments

Name Committee / group
Judi Barratt Obstetric Guidelines/Patient Information Group

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